Vol 56: august • août 2010 Canadian Family Physician•Le Médecin de famille canadien
773
Tools for Practice
Treatment of pediatric fever
Are acetaminophen and ibuprofen equivalent?
G. Michael Allan
MD CCFPNoah Ivers
MD CCFPYvonne Shevchuk
PharmDClinical question
Is acetaminophen or ibuprofen superior for the treat- ment of pediatric fever?
Evidence
A meta-analysis and recent randomized controlled trial provide some guidance.
• Meta-analysis of 10 trials (N = 1078) of ibuprofen (5 to 10 mg/kg) versus acetaminophen (10 to 15 mg/kg)
1: -ibuprofen was superior at 2, 4, and 6 hours; and -at 4 to 6 hours, approximately 15% more ibuprofen
patients had fever reduction (number needed to treat = 7).
• PITCH randomized controlled trial (N = 156, aged 6 months to 6 years) comparing ibuprofen (10 mg/kg every 6 to 8 hours), acetaminophen (15 mg/kg every 4 to 6 hours), or a combination of both
2:
-For time without fever in the first 4 hours, the com- bination was superior to acetaminophen by 55.3 min- utes (P < .001) but was not superior to ibuprofen.
-Ibuprofen and the combination cleared fever faster.
-The combination reduced fever time in the first 24 hours (acetaminophen 4.4 hours more [P < .001], ibu- profen 2.5 hours more [P = .008]).
-Overdose was reported in 33 children (21%).
-The authors recommended ibuprofen:
—ibuprofen was superior to acetaminophen;
—the combination was only slightly better on a few outcomes than ibuprofen alone; and —there was a possible risk of excess dosing
with the combination.
Context
Some debate surrounds the use of antipyretics:
• There is no evidence that fever itself is harmful (theo- rized that it might be part of the immune response).
3• Antipyretics do not seem to prevent febrile seizures.
4• There is no evidence that treating fever in mild infec- tions is harmful (unless overdosed).
• If fever is treated, the goal should likely be comfort
5(although no studies have investigated comfort in fever).
Adverse effects of ibuprofen compared with acetaminophen:
• asthma—no increased risk or perhaps slightly lower
6(possible slight increase with acetaminophen
2);
• Reye syndrome—no increased risk
7,8;
• gastrointestinal and renal effects—no evidence of risk,
9but the Canadian Paediatric Society advises against ibu- profen if a child is not “drinking reasonably well”
5; and
• systemic reaction—no evidence of risk.
7Bottom line
The appropriateness of treating pediatric fever is controversial and should be discussed with parents.
If clinicians are going to recommend a treatment, they should know that ibuprofen offers superior fever reduction with no increase in adverse events.
Implementation
Providing pamphlets about fever management can reduce parental anxiety and decrease emergency visits.
10Although the evidence for patient information leaflets is gener- ally poor,
11pamphlets about pediatric infections seem to work if they are reviewed during the clinical encoun- ter.
12Therefore, reviewing the Canadian Paediatric Society handout
5with parents to explain fever management might be helpful, but the pamphlet could be altered to encourage ibuprofen use with appropriate dosing regimens.
Dr Allan is an Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton and the Medical Director of Toward Optimized Practice. Dr Ivers is a family physician at Women’s College Hospital in Toronto, Ont.
Dr Shevchuk is a Professor in the College of Pharmacy and Nutrition and an Associate Member of the Division of Infectious Disease at the University of Saskatchewan.
the opinions expressed in this Tools for Practice article are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.
References
1. Perrott DA, Piira T, Goodenough B, Champion GD. Efficacy and safety of acetamino- phen vs ibuprofen for treating children’s pain or fever: a meta-analysis. Arch Pediatr Adolesc Med 2004;158(6):521-6.
2. Hay AD, Costelloe C, Redmond NM, Montgomery AA, Fletcher M, Hollinghurst S, et al. Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): ran- domised controlled trial. BMJ 2008;337:a1302. Erratum in: BMJ 2009;339:b3295.
3. Mackowiak PA. Physiological rationale for suppression of fever. Clin Infect Dis 2000;31(Suppl 5):S185-9.
4. Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures. Febrile seizures: clinical practice guideline for the long-term man- agement of the child with simple febrile seizures. Pediatrics 2008;121(6):1281-6.
5. Caring for kids [website]. Fever and temperature taking. Ottawa, ON: Canadian Paediatric Society; 2009. Available from: www.cps.ca/caringforkids/whensick/
Fever.htm. Accessed 2010 Jun 21.
6. Kanabar D, Dale S, Rawat M. A review of ibuprofen and acetaminophen use in febrile children and the occurrence of asthma-related symptoms. Clin Ther 2007;29(12):2716-23.
7. Southey ER, Soares-Weiser K, Kleijnen J. Systematic review and meta-analysis of the clinical safety and tolerability of ibuprofen compared with paracetamol in paedi- atric pain and fever. Curr Med Res Opin 2009;25(9):2207-22.
8. Lesko SM, Mitchell AA. The safety of acetaminophen and ibuprofen among children younger than two years old. Pediatrics 1999;104(4):e39.
9. Lesko SM, Mitchell AA. An assessment of the safety of pediatric ibuprofen. A practi- tioner-based randomized clinical trial. JAMA 1995;273(12):929-33.
10. O’Neill-Murphy K, Liebman M, Barnsteiner JH. Fever education: does it reduce par- ent fever anxiety? Pediatr Emerg Care 2001;17(1):47-51.
11. Nicolson D, Knapp P, Raynor DK, Spoor P. Written information about individual medicines for consumers. Cochrane Database Syst Rev 2009;(2):CD002104.
12. Francis NA, Butler CC, Hood K, Simpson S, Wood F, Nuttall J. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised con- trolled trial. BMJ 2009;339:b2885.
